Healthcare Provider Details

I. General information

NPI: 1245234202
Provider Name (Legal Business Name): STEPHEN M BRENNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 11/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHRISTIE PLACE, #407
SCARSDALE NY
10583-0000
US

IV. Provider business mailing address

1 CHRISTIE PL # 407
SCARSDALE NY
10583-8302
US

V. Phone/Fax

Practice location:
  • Phone: 914-723-9113
  • Fax: 718-601-5642
Mailing address:
  • Phone: 914-723-9113
  • Fax: 718-601-5642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number090574-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number090574-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: